Provider Demographics
NPI:1194113464
Name:CLARK, DAVID R (PA-C)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:R
Last Name:CLARK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6136 PETERS CREEK RD
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24019-4028
Mailing Address - Country:US
Mailing Address - Phone:540-283-3660
Mailing Address - Fax:540-283-3677
Practice Address - Street 1:1942 BRAEBURN CIR
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-7388
Practice Address - Country:US
Practice Address - Phone:540-444-1240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-08
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110-004821363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1194113464Medicaid
VVH533AMedicare PIN